UNICEF UK BABY FRIENDLY INITIATIVE THEORY OF CHANGE INTRODUCTION

The Baby Friendly Initiative offers an evidence ©Unicef UK/Jennings based approach to supporting and good infant nutrition, and helping parents to develop close and loving relationships with their babies.

Our ‘Theory of Change’ explains how this programme works to improve child nutrition, health and development by working with a range of health professionals and students to raise standards of care for babies, their mothers and families. A full review of the evidence for the Baby Friendly programme is available here: .uk/babyfriendlyevidence

SUPPORTING AND PROTECTING BREASTFEEDING

The benefits of breastfeeding for babies,1,2 face-to-face, ongoing, tailored and predictable mothers3 and public health4,5 are well breastfeeding support by trained personnel, established. It protects children from a vast starting during pregnancy and continuing range of illnesses including infection, diabetes, through the postnatal period, can increase the asthma, heart disease and cot death (Sudden duration and exclusivity of breastfeeding.16 Infant Death Syndrome), as well as obesity, a major public health priority.6,7,8 It also protects There is strong evidence for the Baby Friendly mothers from breast and ovarian cancers and programme as a key intervention for supporting heart disease.3,9,10,11 In addition, it supports the breastfeeding. Studies looking at the impact mother-baby relationship and the mental health on UK breastfeeding rates have shown that of both baby and mother.11,12,13 Despite explicit giving birth in a Baby Friendly facility increases commitment to promoting breastfeeding in the breastfeeding initiation.17,18 International UK, there are still gaps in provision of support studies have also shown a positive impact of and rates remain lower than in many other high Baby Friendly on breastfeeding initiation and income countries.14 duration, including in the US,19,20 Turkey,21 Switzerland,22 Belarus23 and in multi-country In the UK, most women want to breastfeed but studies.24,25 many face difficulties early on and eight out of ten stop before they want to.15 The provision of

SAFER FEEDING AND NUTRITION

The Baby Friendly Initiative works with public the most appropriate formula, make up feeds services to ensure that families receive effective and give feeds as safely as possible. infant feeding support, enabling them to make an informed choice about feeding, get Responsive feeding has benefits for a baby’s breastfeeding off to a good start, overcome emotional and cognitive development,26 as well challenges and feed their babies responsively. as self-regulating intake and reducing Parents who formula feed are supported to use obesity later in life.27 Responsive feeding is

THEORY OF CHANGE: UNICEF UK BABY FRIENDLY INITIATIVE 1 more common among breastfeeding mothers;28 . Parents receive mixed messages about as a breastfed baby cannot be overfed, mothers when to introduce solids,30 and few (c. 6%) can use breastfeeding to respond to their baby’s wait until the recommended six months.15 Early need for comfort as well as nutrition. Whilst not introduction of solids is associated with reduced the same, responsive feeding practices can also breastmilk intake and may increase the risk of be encouraged in bottle feeding.29 obesity.31 The Baby Friendly standards require that mothers are supported to maximise their Recognising babies’ cues and being responsive breastmilk and introduce solids appropriately. to them continues in the introduction of solid

SUPPORTING CLOSE AND LOVING RELATIONSHIPS

©Unicef UK/Jennings Responsive parenting is crucial for early childhood development and for physical and emotional wellbeing.32 Interventions that support families in the critical early days and weeks can help give them the confidence and skills to develop those close relationships.33,34 This includes giving information about skin- to-skin contact, understanding their babies’ cues, responding to them and implementing safe sleeping practices. Crucially, parents are informed about the impact that a close and loving relationship will have on their baby’s brain development and wellbeing, and are supported to develop this relationship regardless of feeding method.

CREATING A SKILLED, SUPPORTIVE WORKFORCE

Offering effective support to parents is only Women need to feel that breastfeeding and possible when practitioners have sufficient developing close and loving relationships is knowledge and skills. When practitioners lack valued and that they will be supported; mothers this knowledge and offer conflicting information can be discouraged from breastfeeding by they can discourage mothers and undermine negative attitudes of health professionals.35 A confidence in their parenting decisions.35 positive culture facilitates breastfeeding and skin-to-skin contact and enables mothers to be Research has found major deficits in with their baby as much as possible.35 knowledge, skills and attitudes of health practitioners resulting in poor provision of A supportive culture for breastfeeding can information and support to mothers.36 As well be undermined by perceived endorsement of as knowledge about breastfeeding, practitioners formula as an alternative to breastfeeding. The need the skills to communicate with mothers International Code of Marketing of Breastmilk in a way that is clear, helpful, mother-centred Substitutes37 aims to regulate advertising and non-judgemental. However, communication of breastmilk substitutes both to protect skills are sometimes poor and fail to take breastfeeding and to ensure that parents into account mothers’ needs and wishes.35 who formula feed receive clear and accurate Institutions need to provide training, develop information about products. The Code has been better policies and enhance skills across all partially implemented into UK law, and the Baby practitioners, not just a handful of specialists.36 Friendly Initiative plays an important role in This approach is required by the Baby Friendly monitoring and ensuring compliance with the standards, along with regular, ongoing audit Code.38,39 and practice reviews to ensure that staff skills are maintained at a high level.

THEORY OF CHANGE: UNICEF UK BABY FRIENDLY INITIATIVE 2 BABY FRIENDLY NEONATAL UNITS

For sick or premature babies and their parents, Baby communicating with and touching their baby as Friendly neonatal units can make all the difference. appropriate to their condition. Units must show commitment to supporting mothers to achieve Each year in the UK, around 1 in 10 babies this and to explain the benefits for mothers and are admitted to neonatal units, having babies. been born sick or premature.15 For parents, neonatal units can be deeply stressful and CASE STUDY: LISTER HOSPITAL disempowering, highly technical environments in which they may feel ill-equipped to voice Daisy was born prematurely at Lister opinions on their baby’s treatment and where Hospital in Stevenage. Daisy’s mother opportunities to touch, hold and comfort their described the powerful need to touch and baby are often restricted. This separation hold her baby: is also highly distressing for babies, raising ■■ “It’s very scary having a baby in an incubator; their levels of the stress hormone cortisol, you naturally want to hold and touch and with serious implications for their brain and comfort, and when you do it is a very magical emotional development.40,41 These barriers moment.” create difficulties in establishing and fostering a As part of implementing the Baby Friendly loving and responsive parent-child relationship, Standards, Lister Hospital provided comfy impacting both parents’ and baby’s mental chairs to enable skin-to-skin contact health and making the transition home much between parents and their baby on the more challenging. This environment also neonatal unit. makes it more difficult for babies to receive the ■■ “These lovely comfy chairs make us feel breastmilk they need to survive and develop. secure, which is what we need as our

©Unicef UK/Shah babies are so tiny when they are born and very fragile; you are scared to pick them up. To be in a secure chair makes you feel a lot more comfortable and at ease.” ■■ “Skin-to-skin benefits both of us. She picks up on my smell; she would be a lot calmer and I felt it did the same for me. I would be worried and scared, but the minute I had her on me I didn’t really think of anything else. We would just be in the minute together having a lovely cuddle.” ©Unicef UK/Jennings

The Baby Friendly Initiative standards provide a roadmap for units to transform their care by supporting parents to develop a close and loving relationship with their baby, enabling babies to receive breastmilk and to breastfeed where possible, and valuing parents as partners in their baby’s care. In this way parents’ voices are put at the heart of care, and opportunities for parents to bond with their baby are prioritised, second only to survival. For example, the standards include providing new mothers with the opportunity for skin-to-skin contact with their babies as soon as possible after birth. Parents are actively supported to comfort and respond to their baby’s needs by

THEORY OF CHANGE: UNICEF UK BABY FRIENDLY INITIATIVE 3 THEORY OF CHANGE: BABY FRIENDLY INITIATIVE

BREASTFEEDING CULTURE PARENT-BABY RELATIONSHIP CHILD NUTRITION

External assessment Conferences and Audit and practice tools and accreditation support networks

Training staff Evidence-based standards Lobbying and advocacy Evidence-based resources and managers ACTIVITIES

Improved practitioner Baby Friendly policies Sustained management Information resources knowledge, skills Effective ongoing in hospital and commitment to available for parents

OUTPUTS and attitudes audit processes community settings Baby Friendly standards and staff

Practitioners offer effective Staff culture supports safe Appropriate spaces & facilities Practitioners and parents have meaningful conversations breastfeeding support in infant feeding available for breastfeeding about safe infant feeding and

PRACTICE hospital and community and responsive parenting and responsive parenting responsive parenting CHANGES IN CHANGES IN AND CULTURE AND

Parents are more informed Enabling environment for Staff culture supports Parents understand benefits and confident in breastfeeding, skin-to-skin & safe infant feeding of responsive, close and feeding practices responsive parenting in hospital and responsive parenting loving parenting

Responsive, close and loving

CARE AND FEEDING Increased initiation and Increase in safer, responsive Increase in appropriate parenting (increased skin-to- CHANGES IN INFANT CHANGES IN INFANT continued breastfeeding formula feeding introduction of solid foods skin, safe bed-sharing)

Reduction in childhood Improved outcomes throughout Reduced inequality hospitalisations children’s lives of outcomes

Reduced instances of serious Reduction in Improved emotional childhood illness childhood obesity health of children LONG TERM IMPACT LONG TERM IMPACT IN CHILDREN’S LIVES

THEORY OF CHANGE: UNICEF UK BABY FRIENDLY INITIATIVE 4 REFERENCES

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